Otago University final-year medical student Kapowairua Stephens, 26, is close to realising her dream of being a doctor because of the Māori entry pathway. Photo / Supplied
Not everyone gets to study the university course they want and the way we pick medical students has proven especially controversial. As school leavers and older workers alike consider their options for 2021, Simon Collins and Kirsty Wynn explain the admissions debate in the final of a three-part series.
Preferred minority groups now take a majority of the places in our two medical schools - but it's still not enough to make our doctors look like us.
Just 120 of the 257 places for domestic students entering medicine at the University of Auckland next year will be available for "general" students, after allocating 77 to Māori and Pacific students, 52 to regional and rural students, five to students from decile 1-3 schools, two to students with disabilities and one to a student from a refugee background.
At the University of Otago, only 82 of the 199 places for domestic students entering this year from first-year health sciences were available to general students after giving preference to 55 Māori, 31 rural students, about 20 Pacific students, about 10 students from decile 1-3 schools and one refugee.
The preference schemes are raising the hurdles for non-preferred students to get into popular courses like medicine. Reports that "general" students needed at least 94 per cent in first-year health sciences to get into medicine at Otago this year have sparked a controversial review of Otago's preference system.
Yet the schemes are still making glacially slow progress towards making our professions look like the society they serve.
Māori have increased from 2.3 per cent of our doctors in 2000 to 3.8 per cent, but are still well short of the Māori share of the NZ population, 16.5 per cent.
Pacific doctors have risen from 1.1 per cent to 1.8 per cent, compared with 8.1 per cent of the population.
Only 11.6 per cent of our teachers, 7 per cent of nurses, 6.1 per cent of lawyers and just 0.5 per cent of vets are Māori.
Pacific people make up only 3.9 per cent of teachers, 3.4 per cent of nurses, 2.8 per cent of lawyers and 0.3 per cent of vets.
Despite setting ethnic targets since 2008, Auckland University Deputy Vice Chancellor John Morrow says there often haven't been enough applicants to fill all the quotas for preferred groups.
"We simply haven't had sufficient qualified candidates applying for certain programmes, so the so-called quotas haven't been filled," he says.
A university spokesperson, in written answers to Herald questions, blames "the way the school system perpetuates bias for Māori and Pacific students".
"Choosing what subjects you do at school is really complex and our first-in-family students will come from families who may not have the background knowledge to guide their kids, so they have to be guided by the school," the spokesperson says.
"The students and their families may not appreciate the difference between internal and external credits, and how each prepares a student for future study. If the school pushes those students towards taking all internal credits, that's a form of bias."
Historically, NZ universities have been open to anyone leaving school with University Entrance (UE), and entry is still guaranteed by law to all New Zealanders aged 20 or over whether they have UE or not.
However, the law allows the universities to restrict numbers for particular programmes if required "because of insufficiency of staff, accommodation or equipment".
In practice, entry is still open to almost all courses at all universities except Auckland, with exceptions such as veterinary science at Massey and medicine and law at Otago.
But the funding incentives for universities changed around the year 2000 when internet search engines made it feasible for global agencies to start ranking universities based on the number of times their academics were quoted in "top" world journals.
High rankings attracted more international students, who paid fees averaging $29,200 per equivalent-fulltime student at Auckland in 2018 - much more lucrative than the $18,600 that each fulltime domestic student brought in through fees and state funding.
Helen Clark's Labour Government reinforced the emphasis on research publications, rather than teaching, by creating a "performance-based research fund" in 2003 that gave universities research funding based on their academics' research "outputs", their numbers of postgraduate "research degrees" and their external research income.
Auckland University adopted a deliberate policy of creaming off the country's top students for almost all of its courses, declaring an aim in 2005 to "achieve a high-quality student body" by limiting student growth to 1 per cent a year and setting admission standards for all programmes.
Its current strategic plan for 2013-2020 aims to "enhance the university's international rankings" by attracting higher proportions of postgraduate and international students, reducing the proportion of domestic undergraduates.
Its annual reports since 2009 have recorded targets of gradually increasing the proportion of school-leavers admitted to the university with a "grade point equivalent" of at least 5 in the National Certificate of Educational Achievement (NCEA) from 33 per cent of students coming straight from school in 2006 to 60 per cent last year.
A grade point equivalent of 5 equates to an NCEA "rank score" of 240-249.
The rank score is based on 2 points for achieved, 3 points for merit and 4 points for excellence in a student's best 80 level-3 credits across four or five approved subjects, so a rank score of 240 requires at least a merit average (80 x 3).
University Entrance normally requires only 60 credits at NCEA level 3 including at least 14 credits in each of three approved subjects and including at least 10 in courses that prove basic literacy and numeracy. (Students must also have at least 20 further credits at level 2 or above).
Achieving 60 credits with no merits or excellences would get a student into another university with a rank score of 120 (60 x 2), so Auckland requires 60 per cent of its students to have at least double the normal requirement.
However, it is also a publicly-owned institution with social objectives including "a diverse student body" and "partnerships that acknowledge the principles of the Treaty of Waitangi", so it has made exceptions from the normal rules for Māori, Pacific, disabled, low-decile and refugee students.
At Auckland University, the actual rank scores required vary by subject from 150 for degrees in arts or teaching up to 165 for science, 180 for commerce, 230 for architecture, 250 for health sciences and 260 for engineering.
Maximum domestic and international student numbers are set for each course, ranging from 27 domestic places for a Bachelor of Dance up to 2250 for a Bachelor of Science.
Within those maximum numbers, quotas are set for Māori, Pacific, disabled, low-decile and refugee students who don't have the required rank scores.
Students from those groups who do have the required rank scores don't need to use the preference system. At Auckland, 80 per cent of Māori students and 70 per cent of Pacific students get in through the general system and don't apply for preferential entry.
The total quotas for preferential entry for those without the normal requirements range from 10 per cent of the domestic places available in engineering, and 11 per cent in commerce, up to a third of domestic places in medicine and pharmacy.
Entry into health professional courses such as medicine, which start in the second year, is based on grades in first-year papers with a minimum averages of 75 per cent for medicine, 70 per cent for pharmacy or 65 per cent for nursing.
Entry to second-year law is based on grades in first-year papers, with a slightly lower minimum grade in one key paper for students in the preferred groups.
Health professional courses also have an additional quota of 20 per cent for "regional and rural" students. Auckland University defines them as all students who attended schools outside Auckland, Hamilton, Tauranga, Wellington, Christchurch and Dunedin.
Regional and rural students still have to meet the same minimum averages as general students, but are ranked separately to fill their 20 per cent quota so their effective minimum first-year grade may be lower than for general students.
For the other preference groups, lower NCEA rank scores are set ranging from a bare UE (rank score 120) for arts, teaching and architecture up to rank scores of 140 for science and 220 for engineering.
In commerce, Māori, Pacific and disabled students only need a rank score of 140, but low-decile and refugee students need 165 and all other students 180.
In first-year health sciences, no specific rank score is set for first-year Māori and Pacific students, but disabled, low-decile and refugee students need a rank score of 220 compared with 250 for general students.
As Morrow says, the quotas are not always filled. In engineering, 94 out of 945 domestic places were reserved for preferential entry groups this year, but only two Māori students - and none from any other group - actually used the quota to get in.
In science and teaching, there are no quotas on the numbers who can get in through the preference schemes because current total student numbers are well below the maximum numbers allowed.
But where numbers are limited, the quotas are filled first, in rank order, and then the remaining domestic places are allocated to all other domestic applicants, again in rank order.
In the most selective subjects, only 56 per cent of applicants for medical and health sciences, and just 36 per cent of applicants for architecture, got into those courses last year.
Unlike Auckland, Otago University does not restrict student numbers in any courses except health professions and law.
For all other subjects, it offers guaranteed "preferential entry" to domestic students with UE and an NCEA rank score of 140 - in other words, at least 70 achieved level 3 credits (70 x 2) or 60 credits with some merits or excellences.
Māori and Pacific students don't even need a rank score of 140; they can get preferential entry with a bare UE requiring a rank score of 120.
However, Otago operates a much stronger preferential system than Auckland in its medical school, where it aims explicitly to achieve a health workforce that is a "mirror on society" - reflecting the demographic makeup of the wider NZ population.
Students all do either a first-year health sciences paper or a whole degree, and then apply for professional courses where the numbers are restricted, including 282 for medicine, 120 for pharmacy and 60 for dentistry.
The basic requirements for entry from first-year health sciences are achieving at least 70 per cent in every first-year paper plus passing a clinical aptitude test.
Māori, Pacific, decile 1-3, refugee and rural students can go into a separate queue who have all, until now, been guaranteed entry to the professional courses if they achieve the basic requirements of 70 per cent in first-year courses plus the aptitude test.
Students in the preferred groups don't have to disclose their origins and can apply through the general queue if they want to.
But, unlike Auckland, there are no "quotas" or caps on the numbers admitted through the preferred-groups queue, so their numbers have been allowed to grow to the point where this year 117 of the 199 places available to first-year health sciences students went to the preferred groups, leaving 82 for general entry.
The university won't confirm or deny that the 82 students entering from the general queue had to get at least 94 per cent in their first-year papers.
The system is now under review.
"Historically, under the health sciences first-year category, it has been possible to admit all Mirror on Society subcategory applicants who have achieved at least 70 per cent in all first-year health sciences courses and who have met other admission requirements," the university says.
"Whether that will continue to be the case in the future will be addressed as part of a forthcoming process of consultation and review."
Otago's law school also operates a preferential system, for Māori only, for entry to second-year law which is limited to a total of 200 students.
Again, there is no specific Māori quota. The university says admission for all students is "predominantly determined on the basis of students' academic records", but can consider "matters personal to individual applicants, for example that their academic record does not reflect their true ability because they have been disadvantaged by reason of illness, disability or social or economic background".
Massey University's veterinary course is also highly selective, with 297 applicants this year for 100 domestic places in the professional course, which starts after a first-half-year pre-selection stage.
Veterinary science associate dean Eloise Jillings says a Treaty of Waitangi pathway for Māori that has existed since 2007 was broadened this year into a "VetMAP pathway" for Māori and Pacific students.
All domestic applicants first sit two tests which yield a shortlist of 225. who then undergo mini-interviews about eight scenarios to cut the numbers to 100.
Both general and VetMAP students have to achieve the same minimum grades in first half-year courses and pass the two tests, but the VetMAP students are all guaranteed to get to the shortlist of 225.
No other courses at Massey or other universities have similar selective policies, although many have subject-specific requirements such level-3 NCEA maths and physics for engineering courses or certain literacy-rich subjects to do law at Waikato.
Wellington's Victoria University normally requires an NCEA rank score of 150, equivalent to 75 "achieved" credits (75 x 2) or fewer credits with some merits and excellences, although this has been waived for 2021 because of Covid.
It also says Māori and Pacific students who have UE but not the required rank score will be admitted provided that they take part in a mentoring programme. This year, 66 Māori and Pacific students got in under this clause.
Canterbury University requires only UE to do first-year law, but selects 200 students to get into the second year in order of their first-year marks, plus up to 10 places for Māori students who must have at least 50 per cent in two key papers.
Auckland University's 2013-2020 plan aimed to increase international students from 11 per cent of its total equivalent-fulltime students in 2010 to 18 per cent by 2020, and to grow its postgraduate students from 20 per cent to 25 per cent.
By last year, it had over-achieved the first target, lifting overseas students to 20 per cent before Covid hit.
Ministry of Education data use a different definition of postgraduate, but on that measure it also over-achieved, lifting postgraduates from 26 per cent of equivalent-fulltime students in 2010 to 34 per cent.
Domestic undergraduates, whose training was once the university's prime purpose, shrank from 21,470 to 18,810, or from 66 per cent to 55 per cent of all students.
Nationally, all universities have boosted international and postgraduate numbers. Domestic undergraduates have shrunk from 94,700 in 2010 to 85,285, or from 69 per cent to 62 per cent of all students, mainly because the economy was improving until Covid hit so many school-leavers did not need degrees to get jobs.
Māori and Pacific students have also lifted their shares of domestic rolls at all eight universities, with standout gains for Māori at Otago, where one in every eight domestic students is now Māori, and for Pacific students at AUT, where one in five domestic students is Pasifika.
Overall, the Pacific share of domestic university rolls (9 per cent) is now only marginally behind their share of the NZ population aged 18-29 (10.5 per cent).
Māori, however, remain under-represented - 11.8 per cent of domestic university students compared with 19.4 per cent of New Zealanders aged 18-29.
Low-decile schools are even more grossly under-represented. Ministry of Education data show that only 15 per cent of students who left decile 1-2 schools in 2018 started degrees last year, compared with 53 per cent of school-leavers from decile 9-10 schools.
A Herald investigation found in 2018 that the gap was even wider for the most selective courses. Data from six universities showed that 60 per cent of students accepted into second-year courses in medicine, law and engineering came from schools in the richest three deciles, and only 6 per cent from the poorest three.
Otago planning and funding director David Thomson says 50 per cent of Otago's total intake this year came from the richest three deciles in the NZ deprivation index, 35 per cent from the middle four deciles and just 15 per cent from the poorest three deciles.
He says this is mainly because NZ school-leavers with UE are "overwhelmingly middle-class".
Last year, 61 per cent of school-leavers from decile 8-10 schools left with UE, but only 34 per cent in the middle four deciles and 20 per cent in the poorest three.
Even if they have UE, he says many students from poorer families are scared off university by the cost.
Education systems are constantly evolving, and the universities' current student selection policies are being pulled in opposite directions.
From the right, Act Party leader David Seymour argues that "people should never be discriminated against on the basis of their ethnic background".
"Yes, we should have doctors who are capable of dealing with Māori. Yes, we should have doctors who are capable of dealing with Pacific people, and with Chinese and Indians who are also significant cultural minorities in NZ now," he says.
"But it's not obvious that a person's ethnic background is the best criteria for that."
From the left, former Otago medical school dean Professor Peter Crampton, who developed the Mirror on Society policy, suggests that the current system of accepting students in rank order of their academic grades should be replaced - perhaps even by a ballot of all those who achieve required minimum standards.
"If you actually say to people, what do you look for in a doctor, most people say, 'Well, I like my doctor to be caring, a good communicator, empathetic," he says.
He says those who complain that high-performing students can't get into medical school are "putting huge emphasis on the needs of the individual".
"I'm putting the emphasis on the needs of society and health outcomes," he says.
Having 30 per cent of the class Māori and Pacific changes the culture, helping Māori and Pacific students to feel they belong and helping other students to connect with new cultures.
"They are a pretty tight bunch," he says. "They are intensely supportive of one another. Lifetime friendships are formed."
Auckland University educationalist Dr Melinda Webber, who was the last director of the Starpath project which worked with low-decile schools to lift the numbers coming to university from 2005 until its funding ended in 2017, says universities need to build relationships with students and their whānau early, before their NCEA subject choices close off their options.
"If they could come in Year 10 and talk about what's available at university, their subjects and courses, that would help lift students' aspirations," she says.
She says high-school students need academic counselling from Year 9 with home-class teachers armed with data so that they can say, "Hey, you're doing really well in these subjects, what's happening in this other one?"
"The thing I think we really need to focus on, from primary school, is we need more communication about careers," she says.
"You might say, 'You're good at communication - have you thought about law, have you thought about psychology? Psychology requires you to do these kinds of subjects.'
"You're just planting a seed from a really young age, so we get kids used to looking at university websites and tracking what subjects do I need to do if I want to do that?"
Kapowairua Stephens is a strong intelligent woman, a future doctor who is passionate about improving health outcomes for people in her hometown of Kaitāia.
In her final year of a medical degree at Otago University, Stephens is close to realising her dream of being a doctor - it's a dream that would not have happened without a Māori entry pathway.
Negativity from people who say it's unfair to give Māori students preference on entry to medical school really hurts, she says.
"Having that pathway is so important because it's not just academics and high marks that make a doctor," she says.
"People who come through those pathways bring other insights whether it's understanding rural life, poverty, or the Māori world."
Stephens, 26, says people training to be doctors needed to reflect the society they would one day care for.
"It helps when you know the land and the people and their struggles."
In Kaitāia, Stephens saw first-hand the challenges Māori faced and the gaps in the healthcare system.
Her beloved grandmother died in hospital because of a medical error and it was her death that sparked her interest in medicine.
After her grandmother's death, Stephens met with local doctor Lance O'Sullivan.
"He took me under his wing and said that medicine could be an option for me," she says.
"I loved school, loved sciences and it came together in Year 13."
It was then that Stephens also realised things in Kaitāia "were not as normal as I thought."
"Kaitāia is a highly Māori and lower socio-economic community and I thought it was normal to have family in hospital, normal to see drug and alcohol use from a young age, normal to see poverty and all of those negative things."
"There is a lot that needs to be done to improve healthcare for people in the community and that is what I want to help with."
Stephens entered an educational bridging programme called Tū Kahika that gave her confidence in science and taught her how to study.
"I did quite well with that and from there I gained a Māori entry scholarship which was around $15,000 to help pay for fees and accommodation."
Stephens then applied to med school under both the Māori entry pathway and the rural pathway. She gained entry under the Māori pathway and says any negativity from fellow students was forgotten once classes started.
"Once you are in, you 100 per cent have to achieve the same marks as everyone else so any negativity is forgotten about," she says.
"If you don't make the mark you don't make the mark, but if you don't pass an assessment everyone gets support - they can't afford to lose medical students once they are in."
That's not to say Stephens hasn't been judged because of the pathway entry.
"I have heard from friends of friends that I have taken their place. That really hurts because I know the hours I have studied to make sure I succeed."
Stephens says it took her a long time to realise her purpose wasn't to prove those people wrong.
"I realised what I needed to do was to succeed and go home to Kaitāia to be a great doctor," she says.
"I sometimes caught myself wondering if I deserved to be there but I remind myself I am there for the people of Kaitāia, not just myself."
Kalin Geisreiter went into university not knowing exactly what he wanted to do but with a passion for both music and science.
The talented guitarist, now 24, decided to study music at Otago University but after the first year decided his interest in science was more likely to lead to a life-long career.
"Music really appealed to me and I had a passion for music and love playing the guitar," Geisreiter says.
"I soon realised after speaking to people who had done the same music degree that they hadn't got jobs and I didn't fancy paying $70,000 for a music degree I couldn't use."
With a good knowledge of science from days at Otago Boys' High School and an interest in anatomy, Geisreiter chose to study health science with a view to get into medical school.
"It was a great year with parts I loved but in terms of getting into medical school through health science you needed an A or even an A + grade," Geisreiter says.
"It's extremely competitive, so I didn't get in."
Geisreiter looked at other pathways into medical school including looking "deep into my family tree" for Māori ancestry because he knew about the preferential entry for Māori students.
"I couldn't find a drop of Māori blood, unfortunately," he says.
"Some of my colleagues got in with a B average and some others, who had more of an interest or who had done better, didn't get in."
Despite not getting in himself, Geisreiter saw the need for preferential entry for Māori, rural, and Pasifika people.
"I work in the industry now so I know that is important," he says. "But I think the issue is they are not letting enough people in overall."
He says the total number of people on the course needed to increase to meet the demand for health professionals.
"There are people who really deserve to get in but they only let in 120 a year, the number is too low."
"There is still the issue we have now where there are not enough health professionals."
After his unsuccessful attempt at medical school, Geisreiter decided to concentrate on the parts of the health science course he was most passionate about, and majored in anatomy.
"There was a bit of chopping and changing but I think it's important to be able to change something if it is not working for you," he says.
"After I changed to anatomy I found it was ticking my boxes and I was doing everything I liked."
There was practical work such as dissecting cadavers and learning by sight and touch rather than rote learning.
Geisreiter graduated with a Bachelor of Science in anatomy and is now working as an orthopedic product specialist - a job he never knew existed but that encompasses everything he enjoys.
"I'm working with doctors and giving support to medical staff in Dunedin, Invercargill and Timaru hospitals and am always problem-solving."
"I attend surgeries and if there is an issue with the equipment, I am there to offer advice and support."
Geisreiter says the company he works for is dedicated to retaining staff and providing future advancement.
"I am really happy with my job and there it's a good company that has plenty of opportunities to grow and learn new skills," he says.
"I have a job that helps me pay my student loan and my mortgage and one where I use my degree every single day."
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